<!DOCTYPE html>
<html>
    <head>
        <meta http-equiv="Content-Type" content="text/html; charset=UTF-8">
        <title>Member Registration</title>
    </head>
    <body>
        <div>
            <h1>Registration Form</h1>
            <h2>Please fill all the information below</h2>
            <form method="POST" action="">
                <fieldset>
                    <legend>User Details</legend>
                    <label>NRIC</label>
                    <input type="text" name="nric" value="" placeholder="NRIC" required/>
                    <br>
                    <label>First Name</label>
                    <input type="text" name="firstname" id="firstname" value="" placeholder="First Name" required/>
                    <label>Last Name</label>
                    <input type="text" name="lastname" id="lastname" value="" placeholder="Last Name" required/>
                    <br>
                    <label>DOB</label>
                    <input type="date" name="dob" id="dob" value="" placeholder="dd/MM/yyyy"/>
                </fieldset>
                <fieldset>
                    <legend>Contact Address</legend>
                    <label>Email</label>
                    <input type="email" name="email" id="email" value="" placeholder="example@domain.com"/>
                    <br>
                    <label>Address</label>
                    <textarea id="address" name="address"></textarea>
                    <br>
                    <label>Postal Code</label>
                    <input type="text" name="postalcode" id="postcalcode" value="" placeholder="123456"/>
                    <br>
                    <label>Office Phone</label>
                    <input type="tel" name="officephone" id="officephone" value="" placeholder="12345678"/>
                    <label>Mobile Phone</label>
                    <input type="tel" name="mobilephone" id="mobilephone" value="" placeholder="12345678"/>
                    <label>Home Phone</label>
                    <input type="tel" name="homephone" id="homephone" value="" placeholder="12345678"/>
                </fieldset>
                <fieldset>
                    <legend>Beneficiary Info</legend>
                    <label>NRIC</label>
                    <input type="text" name="bnric" value="" placeholder="NRIC" required/>
                    <br>
                    <label>First Name</label>
                    <input type="text" name="bfirstname" id="bfirstname" value="" placeholder="First Name" required/>
                    <label>Last Name</label>
                    <input type="text" name="blastname" id="blastname" value="" placeholder="Last Name" required/>
                    <br>
                    <label>DOB</label>
                    <input type="date" name="bdob" id="bdob" value="" placeholder="dd/MM/yyyy"/>
                </fieldset>		
				<input type="button" value="Register"/>		
				<input type="reset" value="Clear"/>				
            </form>
        </div>
    </body>
</html>